06-13-2017, 04:49 AM
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AAPC Community Wiki: Punch Biopsy - If the provider does

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You will find your answer in the two examples mentioned in the excerpt from the biopsy guidelines which are from the CPT 2004 page 50 of the Professional Edition:

A skin biopsy procedure differs in several ways from other integumentary system procedures, such as excision, destruction, or shave removals. First, the intent of a biopsy is different and the procedure itself can vary somewhat from the other procedures. A skin biopsy may be performed on a lesion or on certain areas of skin to diagnose certain skin diseases or systemic conditions. The intent of a biopsy is to remove a portion of skin, suspect lesion, or entire lesion so that it can be examined pathologically. For example, a punch biopsy may be performed to obtain a portion of tissue from a skin lesion. The wound may be closed with a suture. The removed tissue is the biopsy specimen, which is sent for pathological examination. Code 11100 may be reported for such an instance.

The intent of other integumentary system procedures that involve removal of tissue is different. Generally, they are performed for the purpose of removing an entire lesion. The following example regarding excision of a skin lesion should be contrasted against the prior discussion about biopsy procedures. The intent of an excision procedure is to remove the entire lesion along with a margin of normal tissue around it. A nevus is entirely removed with the use of a punch and the wound is closed with one suture. The removed nevus, with its margin of normal tissue, is sent for pathological examination. Depending on the final diagnosis in the pathology report, the appropriate code from either 11400-11446 (benign) or 11600-11646 (malignant) may be reported. Obtaining or removing the tissue in this procedure is part of the procedure itself, ie, removing the lesion in this manner is the procedure. It is not considered a separate biopsy procedure; therefore, a biopsy code is not separately reported.

If the provider does a punch biopsy but removes the entire lesion with the punch would this be coded as an excision because he removed the entire lesion or would it still be a punch biopsy 11100 since that was the manner in which it was removed?

If the provider does a punch biopsy but removes the entire lesion with the punch would this be coded as an excision because he removed the entire lesion or would it still be a punch biopsy 11100 since that was the manner in which it was removed?

Good question...

My initial instinct was to say 'biopsy', since you mentioned the punch biopsy - I could've sworn that the CPT descriptions, or guidelines, mentioned that by name, but I can't find it anywhere, now.

In fact, neither the biopsy or excision codes really mention surgical method(s), except to say that 'shaving of lesions', has its own section of codes. The guidelines under excision state:
"Excision is defined as full-thickness (through the dermis) removal of a lesion, including margins, and includes simple closure when performed...Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision..." - No approach/method is mentioned.

The biopsy guidelines make it pretty clear, that an excision includes a biopsy, but a biopsy doesn't necessarily include an excision. My interpretation of the rules, is that the biopsy codes are used, when only a sample is being taken to send to pathology, and excision codes are for when the whole lesion is removed (and, when needed, sent to pathology).

If the whole lesion was taken, and the provider documented the size w/margins correctly, I'd say go with the excision code, for 3 reasons:
1. The method of removal ('punch biopsy') doesn't appear to be mentioned anywhere in the CPT guidelines or descriptions, that I could find. (If it's in there, someone please tell me where to find it, because now it's gonna bug me!)
2. Regardless of what method was used, it accomplished the same thing as a scalpel excision (assuming it was documented properly, of course) - the whole lesion is gone, and is being sent to pathology.
3. The provider would be short-changing themselves on reimbursement, since biopsy codes are paid at a much lower rate (which is probably because they have the potential to lead to an excision, later on - if my "biopsy = sample" theory is correct.) If he accomplished the work of an excision, then he should be reimbursed, accordingly.

That's just my opinion, though - I'd be interested to see what others think about this one.

The punch is just a tool that takes small samples , sometime the lesion is so small that the puch can remove the entire lesion, and they always go full thickness, this is a punch excision and should be coded as an excision, it is unfortunate the provider uses the term punch biopsy.

My initial instinct was to say 'biopsy', since you mentioned the punch biopsy - I could've sworn that the CPT descriptions, or guidelines, mentioned that by name, but I can't find it anywhere, now.

In fact, neither the biopsy or excision codes really mention surgical method(s), except to say that 'shaving of lesions', has its own section of codes. The guidelines under excision state:
"Excision is defined as full-thickness (through the dermis) removal of a lesion, including margins, and includes simple closure when performed...Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision..." - No approach/method is mentioned.

The biopsy guidelines make it pretty clear, that an excision includes a biopsy, but a biopsy doesn't necessarily include an excision. My interpretation of the rules, is that the biopsy codes are used, when only a sample is being taken to send to pathology, and excision codes are for when the whole lesion is removed (and, when needed, sent to pathology).

If the whole lesion was taken, and the provider documented the size w/margins correctly, I'd say go with the excision code, for 3 reasons:
1. The method of removal ('punch biopsy') doesn't appear to be mentioned anywhere in the CPT guidelines or descriptions, that I could find. (If it's in there, someone please tell me where to find it, because now it's gonna bug me!)
2. Regardless of what method was used, it accomplished the same thing as a scalpel excision (assuming it was documented properly, of course) - the whole lesion is gone, and is being sent to pathology.
3. The provider would be short-changing themselves on reimbursement, since biopsy codes are paid at a much lower rate (which is probably because they have the potential to lead to an excision, later on - if my "biopsy = sample" theory is correct.) If he accomplished the work of an excision, then he should be reimbursed, accordingly.

That's just my opinion, though - I'd be interested to see what others think about this one.

A: Yes. Code 11100 may be reported for a single or first biopsy, regardless of size. However, you should always consider location. If a punch biopsy is taken of certain areas, such as the lip (40490), external ear (69100) or eyelid (67810), it is appropriate to report the code for that specific body area.

I'm a little confused between a biopsy (11100) vs codes in the 11300-11313 range. I have an Ingenix CPT that states shave excision/elliptical excision/punch biopsies should be coded under 11300-11313? That's how I've been coding the punch biopsy. Am I incorrect?

I'm a little confused between a biopsy (11100) vs codes in the 11300-11313 range. I have an Ingenix CPT that states shave excision/elliptical excision/punch biopsies should be coded under 11300-11313? That's how I've been coding the punch biopsy. Am I incorrect?

11100 is just a biopsy - by any method (punch biopsies are usually coded here). The purpose of 11100 is only to take a sample of the lesion, for pathologic examination.

11300-11313 are shave removals. They include a "biopsy", but the purpose is to remove the whole lesion - not just a piece of it. Shave removals are used for lesions that don't extend beyond the dermis. (you might think of them as 'Shallow' lesions). You don't have to send the lesion for pathologic examination, but if you do, it's included in the CPT code.

Excisions (11400-11646), differ from shave removals, in that they are the full-thickness removal of lesions (eg, through the subcutaneous tissue...for removal of 'Deep' lesions). These take margins into account in their diameter-measurements, and include a simple repair (sutures, chemical or electrocauterization of wounds, etc.) They are also classified by 'benign' or 'malignant' - neither shave removals or biopsies include a 'malignancy' aspect (if you already know it's malignant, there's no need to send it to pathology - you'd just cut the whole thing out...)

You would need to look at the provider's intent. If it was to remove the entire lesion using the punch, then it would be considered excision. If the intent was to biopsy, take a sample or piece, then it would be a biopsy code. I think the information that "btadlock1" was looking for is in the CPT® Assistant, October 2004, Skin Biopsy Coding Guidelines. There is more information available in the article as well. I recommend you review that article as well if you have access to the CPT® Assistant References.

“Biopsy Guidelines
The biopsy guidelines from the CPT 2004 (page 50 of the Professional Edition) read as follows:

During certain surgical procedures in the integumentary system, such as excision, destruction, or shave removals, the removed tissue is often submitted for pathologic examination. The obtaining of tissue for pathology during the course of these procedures is a routine component of such procedures. This obtaining of tissue is not considered a separate biopsy procedure and is not separately reported. The use of a biopsy procedure code (eg, 11100, 11101) indicates that the procedure to obtain tissue for pathologic examination was performed independently, or was unrelated or distinct from other procedures/services provided at that time. Such biopsies are not considered components of other procedures when performed on different lesions or different sites on the same date, and are to be reported separately.

To understand the guidelines, it is helpful to know the key distinctions between biopsy and other skin procedures. A skin biopsy procedure differs in several ways from other integumentary system procedures, such as excision, destruction, or shave removals. First, the intent of a biopsy is different and the procedure itself can vary somewhat from the other procedures. A skin biopsy may be performed on a lesion or on certain areas of skin to diagnose certain skin diseases or systemic conditions. The intent of a biopsy is to remove a portion of skin, suspect lesion, or entire lesion so that it can be examined pathologically. For example, a punch biopsy may be performed to obtain a portion of tissue from a skin lesion. The wound may be closed with a suture. The removed tissue is the biopsy specimen, which is sent for pathological examination. Code 11100 may be reported for such an instance.

The intent of other integumentary system procedures that involve removal of tissue is different. Generally, they are performed for the purpose of removing an entire lesion. The following example regarding excision of a skin lesion should be contrasted against the prior discussion about biopsy procedures. The intent of an excision procedure is to remove the entire lesion along with a margin of normal tissue around it. A nevus is entirely removed with the use of a punch and the wound is closed with one suture. The removed nevus, with its margin of normal tissue, is sent for pathological examination. Depending on the final diagnosis in the pathology report, the appropriate code from either 11400-11446 (benign) or 11600-11646 (malignant) may be reported. Obtaining or removing the tissue in this procedure is part of the procedure itself, ie, removing the lesion in this manner is the procedure. It is not considered a separate biopsy procedure; therefore, a biopsy code is not separately reported.”

A. Farmer, CPC

Originally Posted by btadlock1

Good question...

My initial instinct was to say 'biopsy', since you mentioned the punch biopsy - I could've sworn that the CPT descriptions, or guidelines, mentioned that by name, but I can't find it anywhere, now.

In fact, neither the biopsy or excision codes really mention surgical method(s), except to say that 'shaving of lesions', has its own section of codes. The guidelines under excision state:
"Excision is defined as full-thickness (through the dermis) removal of a lesion, including margins, and includes simple closure when performed...Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision..." - No approach/method is mentioned.

The biopsy guidelines make it pretty clear, that an excision includes a biopsy, but a biopsy doesn't necessarily include an excision. My interpretation of the rules, is that the biopsy codes are used, when only a sample is being taken to send to pathology, and excision codes are for when the whole lesion is removed (and, when needed, sent to pathology).

If the whole lesion was taken, and the provider documented the size w/margins correctly, I'd say go with the excision code, for 3 reasons:
1. The method of removal ('punch biopsy') doesn't appear to be mentioned anywhere in the CPT guidelines or descriptions, that I could find. (If it's in there, someone please tell me where to find it, because now it's gonna bug me!)
2. Regardless of what method was used, it accomplished the same thing as a scalpel excision (assuming it was documented properly, of course) - the whole lesion is gone, and is being sent to pathology.
3. The provider would be short-changing themselves on reimbursement, since biopsy codes are paid at a much lower rate (which is probably because they have the potential to lead to an excision, later on - if my "biopsy = sample" theory is correct.) If he accomplished the work of an excision, then he should be reimbursed, accordingly.

That's just my opinion, though - I'd be interested to see what others think about this one.

Originally Posted by btadlock1

11100 is just a biopsy - by any method (punch biopsies are usually coded here). The purpose of 11100 is only to take a sample of the lesion, for pathologic examination.

11300-11313 are shave removals. They include a "biopsy", but the purpose is to remove the whole lesion - not just a piece of it. Shave removals are used for lesions that don't extend beyond the dermis. (you might think of them as 'Shallow' lesions). You don't have to send the lesion for pathologic examination, but if you do, it's included in the CPT code.

Excisions (11400-11646), differ from shave removals, in that they are the full-thickness removal of lesions (eg, through the subcutaneous tissue...for removal of 'Deep' lesions). These take margins into account in their diameter-measurements, and include a simple repair (sutures, chemical or electrocauterization of wounds, etc.) They are also classified by 'benign' or 'malignant' - neither shave removals or biopsies include a 'malignancy' aspect (if you already know it's malignant, there's no need to send it to pathology - you'd just cut the whole thing out...)

A: Yes. Code 11100 may be reported for a single or first biopsy, regardless of size. However, you should always consider location. If a punch biopsy is taken of certain areas, such as the lip (40490), external ear (69100) or eyelid (67810), it is appropriate to report the code for that specific body area.

Disclaimer: Although AAPC staff members will monitor these forums periodically, we cannot be responsible for the information posted herein, nor guarantee its accuracy. Our members may discuss various subjects related to medical coding, but none of the information should replace the independent judgment of a physician for any given health issue. Please note that the opinions expressed here do not necessarily reflect those of AAPC.